Citation Nr: 21065537 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 17-04 647A DATE: October 26, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for a sleep disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2000 to May 2005. These matters are before the Board of Veterans' Appeals (Board) on appeal of October 2015 and May 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a hearing before the undersigned on June 28, 2021. Entitlement to service connection for back, right hip, left hip, bilateral foot, and sleep disorders is remanded. At his July 2021 Board hearing the Veteran reported performing heavy physical labor during service and described low back pain which began in service and continued ever since. He asserted that his claimed back, right hip, left hip and foot disorders were each related to heavy physical labor in service, or alternatively, were caused or aggravated by his service-connected right and left knee patellofemoral pain syndrome. With regard to the claimed sleep disorder, the Veteran reported experiencing difficulty sleeping during service, and alternatively contended that his claimed sleep disorder was caused or aggravated by his service-connected depressive disorder due to chronic pain, with anxious distress associated with patellofemoral pain syndrome, or to pain resulting from his service-connected disorders. The Veteran has not been afforded VA examinations to address the nature and etiology of his claimed hip or sleep disorders. As the Veteran has competently reported current bilateral hip symptoms, a history of performing heavy manual labor during his period of active-duty service and asserts that his hip symptoms are worsened by his service-connected knee disorders, remand is required to obtain VA examinations to consider the nature and etiology of the claimed hip disorders. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Similarly, the Veteran has competently reported sleep problems in service and asserts that his current sleep problems are caused or aggravated by his service-connected depressive disorder due to chronic pain, with anxious distress associated with patellofemoral pain syndrome, or to pain from his other service-connected disorders. Remand is required to obtain a VA examination to consider the nature and etiology of the claimed sleep disorder. Id. The Veteran was provided VA examination for his claimed foot disorders in October 2017. The examiner diagnosed bilateral metatarsalgia but declined to offer any opinion as to the etiology of those disorders on the basis that the examiner was "unable to confirm a current chronic diagnosis." The Board is unable to resolve the examiner's finding of a lack of a current chronic diagnosis with the examiner's own findings of a current diagnosis of bilateral metatarsalgia. Additionally, March 2020 VA treatment records note a diagnosis of right foot degenerative joint disease. Remand is required to obtain an adequate VA examination to consider the nature and etiology of the claimed foot disorders. The Veteran was provided VA examinations for his claimed back disorder in April 2016, April 2017, and August 2020. In April 2016 the examiner diagnosed a lumbosacral strain, but opined against an in-service etiology of that disorder on the basis that there was no documentation of the condition following service. In April 2017 the examiner again diagnosed a lumbosacral strain and opined that the disorder was less likely than not caused by the service-connected left and right knee patellofemoral pain syndrome. The examiner reasoned that the low back disorder was unrelated to the left and right knee patellofemoral pain syndrome and also noted that the Veteran had lumbarization, a congenital anomaly which caused low back pain. In August 2020 the VA examiner diagnosed degenerative arthritis of the spine, degenerative disc disease and congenital lumbarization. The examiner opined against an in-service etiology of a low back disorder, reasoning that the Veteran's service treatment records documented a lumbar strain in service, which typically healed within 3 to 4 months, and that lumbarization was a congenital "anomaly." The examiner further opined that it was less likely than not that a low back disorder was caused by left and right knee patellofemoral pain syndrome on the basis that there was no anatomical, pathophysiological, neuronal, or hormonal correlation to the knee conditions. The examiner did not address whether a back disorder was aggravated beyond its natural progression by a knee condition. Remand is required to obtain a medical opinion which provides separate findings and rationales addressing the separate questions of causation and aggravation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are independent concepts and should have separate findings and rationales). Additionally, while the August 2020 VA examiner noted that the Veteran had lumbarization, described as a congenital "anomaly" it is unclear whether this disorder constitutes a congenital "disease" or "defect" for VA purposes, and whether any congenital defect was subject to a superimposed disease or injury during military service or whether any congenital disease was aggravated by the military service. Remand is also required to address these questions. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back, right and left hip, and right and left foot disorders. The examiner must review the claims file, including the hearing transcript. The examiner should state: a. What diagnosed right and left hip and foot disorders have been present at any time since May 27, 2015 and what back disorders have been present at any time since February 21, 2016? b. For each such disorder, is it at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease, to include heavy manual labor during military service? Why or why not? c. For each such disorder, is it at least as likely as not proximately due to service-connected left and right knee patellofemoral pain syndrome? Why or why not? d. For each such disorder, is it at least as likely as not aggravated beyond its natural progression by service-connected left and right knee patellofemoral pain syndrome? Why or why not? e. Is the Veteran's lumbarization a (1) congenital "disease" or (2) a congenital or developmental "defect?" For VA purposes, "defects" are usually static in nature, whereas "diseases" are generally subject to episodic improvement or worsening. 1) If the Veteran's diagnosed lumbarization is a congenital or developmental defect, is it is at least as likely as not that a superimposed disease or injury occurred during military service that resulted in an additional disability apart from the congenital or developmental defect? Why or why not? 2) If the Veteran's diagnosed lumbarization is a congenital disease, was it aggravated (worsened) by the Veteran's military service? If there was worsening, was this due to the natural progress of the disease? Why or why not? The examiner must discuss the Veteran's lay report of an onset of back pain in service with continuous symptoms since onset. If the examiner finds the lay reports are insufficient to support the claim, the examiner must clearly explain why that is the case. Please be aware that lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. Rationales must be provided for each distinct opinion. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sleep disorders. The examiner must review the claims file, including the hearing transcript. The examiner should state: a. What diagnosed sleep disorders have been present at any time since February 21, 2016? b. For each such disorder, is it at least as likely as not (50 percent probability or greater) related to an in-service injury, event, or disease, to include sleep problems during military service? Why or why not? c. For each such disorder, is it at least as likely as not proximately due to service-connected depressive disorder due to chronic pain, with anxious distress associated with patellofemoral pain syndrome, or to pain resulting from any other service-connected disorder? Why or why not? d. For each such disorder, is it at least as likely as not aggravated beyond its natural progression by service-connected depressive disorder due to chronic pain, with anxious distress associated with patellofemoral pain syndrome, or to pain resulting from any other service-connected disorder? Why or why not? LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bametzreider, Paul J. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.